Tips from Other Journals

Evidence for Management of COPD Exacerbations

Am Fam Physician. 2001 Nov 1;64(9):1614-1619.

Chronic obstructive pulmonary disease (COPD) currently affects more than 16 million adults in the United States, accounting annually for 110,000 deaths, over 16 million office visits, and 500,000 hospitalizations. COPD is characterized by chronic airflow obstruction and episodic increases in sputum production, cough and dyspnea. After an acute episode of exacerbation, patients with COPD have a significant decrease in quality of life that is either transient or permanent. In addition, nearly one half of these patients require readmission within six months after being discharged from the hospital. Therefore, the main treatment goal for patients with COPD is to reduce the frequency and severity of exacerbations. In response to this goal, the American College of Physicians–American Society of Internal Medicine and the American College of Chest Physicians coordinated to develop an evidence-based clinical practice guideline for the management of acute exacerbations in COPD patients.

The guidelines present the available evidence on risk stratification for relapse and six-month mortality, and diagnostic testing and treatments for acute exacerbations of COPD. The guidelines define a patient as being at high-risk for outpatient relapse if, during their hospital visit, they have the following: lower baseline forced expiratory volume in one second (FEV1); low partial pressure of oxygen (PO2); high partial pressure of carbon dioxide (PCO2); low pH and more bronchodilator therapy. Unfortunately, none of the predictive models is accurate enough to warrant uniform use in practice. The authors also concluded that there is currently no reliable method of identifying patients at high risk of inpatient or six-month mortality.

The group produced these eight recommendations for diagnostic and therapeutic interventions in the treatment of patients with COPD presenting to the hospital with an acute exacerbation: (1) chest radiographs performed at hospital admission may be useful; (2) spirometry should not be used to diagnose an exacerbation of COPD or assess its severity; (3) inhaled anticholinergic bronchodilators or short-acting beta2 agonists are beneficial; (4) interventions in those with moderate or severe exacerbations include systemic corticosteroid therapy for up to two weeks, noninvasive positive-pressure ventilation under the supervision of trained physicians and oxygen with caution; (5) narrow-spectrum antibiotics (such as amoxicillin, trimethoprim-sulfamethoxazole and tetracycline) are preferred over the newer, broad-spectrum antibiotics; (6) mucolytic medications, chest physiotherapy and methylxanthine bronchodilators are not useful; (7) no reliable methods of risk stratification for relapse or inpatient mortality currently exist and (8) future research should include the development of a “reproducible, transportable definition of acute exacerbation” in patients with COPD, and randomized, placebo-controlled trials of the newer antibiotics should be performed.

The panel also stated that these clinical practice guidelines are only guides for physicians and may not apply to all patients and all clinical situations. Treatment of individual patients should be based on the physician's clinical judgment.